328- MRI Findings and Low Back Pain

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we are talking research and it is a really cool study that came out in Spine. It is titled association of Lumbar MRI findings with current and future back pain in a Population Based Cohort study. There are a lot of listeners and it might just be you that is going to love some of the facts that come out of this study. We'll break down what it means, what it says and how you can utilize this in the conversations you have with your patients and in your community. On today's episode, before we get started, I'll say a few words about the smart chiropractor. The smart chiropractor can power your patient journey to provide you with more qualified leads, more new patients, better patient retention and consistent reactivations. Drumroll. Without spending any money on advertising, if that sounds interesting to you, Visit us@thesmartchiropractor.com Again, that is www.thesmartchiropractor. but as I said at the top this episode, we're talking research. This came out in Spine in 2021 really cool study. The association of MRI Findings with current and future back pain. This is a topic that has been circling around for a long time. Right? When you see something on an mri, what does it mean? Is it predictive of future back pain? Is it relative to current back pain or is there nothing going on at all? I love this study. And I say this as somebody who practiced in two different stints in two different multidisciplinary orthopedic groups, reviewing a lot of MRIs and I saw surgeons making decisions off of MRI. Yes, there was some case history involved, but elective spine surgery is a big deal. We talk about it all the time on this show. A million plus elective procedures per year. We look at injections which are often done based off of MRI findings. We know there's like 20, whatever it was, 25 million, 9 million ESIs, steroid injections given out each and every year. A lot of the benefit of these things, especially elective, I'm saying, is questionable at best. So let's dive deeper and see what's up. And I'll say one other thing before we dive into the actual study, which is the way that I phrase this in 10, take this, if you will, in your own practice is I always would sit down with the patient. And when I was reviewing MRIs, I'd sit down and say, hey, today we're gonna do three things. Number one is I'm gonna learn a little bit more about why you're here and what's going on, AKA the history. Right. Number two, we're gonna take a look at your MRI and we're gonna separate the not perfects from the problems. And then number three, I'm gonna give you my best course of action, whether it's here or whether it's somewhere else. That framework really suited me well over a pretty long period of time where it built trust and rapport. People know that you're just going to tell them the truth, number one. And number two, it's important to separate the not perfects from the problems. There's many, and we're going to see it in this study many times. You can elaborate a variety of findings on an mri. I always thought of it like a deck of cards. You throw all the whole deck of cards on the table. Those are all the not perfects. That's the three pages or four pages of findings you get on your MRI report. The skill and craft of a physician, of a chiropractor, of a surgeon, of a healthcare professional. Just like you listening. Our skill is in sorting out and seeing that deck of cards spread out all throughout the table and saying, gosh, there's a lot of not perfects, and a lot of that is normal. But let's try to identify the problem with, why did you come in today? What is that? As Steven Fransen would say, life effect. What drove you in here today? Because you can have a lot of not perfects, and that's a. Okay. But my job is to help identify what's the problem, because once you identify that, now you can start moving towards the solution. Final bit of that, if you've seen me do a presentation on interdisciplinary communication and research, basically marketing and talking with MDs and DOs. You see, there's a quote from the the director of Columbia neurosurgery, which is 90% of the time, surgeons don't identify, you know, the problem, so to speak, really the cause of the issue. And there's a lot of work done surgically, not trying to dog surgeons here. There's plenty that do great work. And red flags are one thing, but I've seen it from the inside out that many times there are surgical interventions done on problems, ideally based on the MRI and combined with the case history, but quite often we see them done on the not perfects, and that is a challenge. So why is this such a big deal? We say it before, we'll say it again. Low back pain is a big, big deal, resulting in over $130 billion in healthcare spending. That's just in the United States each year. So is there a market? Yes. Are people looking for answers? Yes. Yes. Are they getting a lot of good answers in a traditional medical system? In my opinion, no. And we see that with guideline discordance as well. So the aim of this study was to take a look at the relationship between lumbar degenerative MRI findings and low back pain in a large cohort, a large population cohort. So they had MRI findings. They were kind of coded in a couple different categories. One, is their disc degeneration greater than grade three, is their disc height loss greater than grade one? Is there any disc herniation? Is there any high intensity zone, any spondylolisthesis? Is there any motic changes, hypertrophy of ligamentum flava? Is there small's node? Or is there spinal stenosis? Those are really the items that they were taking a look for. And here's some of the stats. At baseline, just shy of 60%, 59.5% of participants had low back pain during the last three months with with a mean severity of 4.1 on a 0 to 10 scale. So 4.1 really that high irony here. High, low or lower medium in terms of the severity. Right. 4.1 right in that mid range. So not extreme. And about 60% of people in this study had low back pain during the last three months. So of all of those participants, and this was a large study, but about 24% had no MRI findings. 25% had one MRI finding. Remember we talked about those findings just a moment ago. 21% had two findings, 13% had three. Almost 9% had four, and 8% had five or more different MRI findings. And all of the MRI findings were present among people with and without low back pain. So it was pretty spread out, right? It was a one in four chance that you would have no MRI findings. It was a one in four chance THAT you would have one MRI finding. It was a one in five chance you'd have two. And beyond that you could have three, four or five findings. So important data to understand. About 80%, 77.8 of people with pain at baseline and 75% of people without pain at baseline had at least one MRI finding. So whether you had pain or you didn't, you are around a 75, 76% chance of having at least one MRI finding. So the associations between MRI findings in low back pain severity at follow up were very, very small. And among people with low back pain at baseline, disc degeneration was statistically significantly associated with higher low back pain. Now, the presence of a spondylolisthesis appeared to be associated with moderately greater future pain in those that had no pain at the baseline. So some interesting stats there. Is this predictive? Is this not predictive? Let's keep digging and see what the researchers say about that. They say MRI findings were not predictive of the development of low back pain. And furthermore, they say our findings from a large population based cohort that the our findings from a large population based cohort that the MRI degenerative findings we examined do not have clinically important association with low back pain. Add to recommendations that emphasize a cautious use of MRI in back pain patients. So that is your takeaway message. And when I talk, I call this the patient journey of professional indifference. And what I mean by that is you've seen this, this happens every single day in your community. And I can't emphasize that enough. Somebody has low back pain, they don't go to see you, they go to see an urgent care provider, an md, potentially a do. And I'm not trying to again dog those, those healthcare professionals or, you know, but this is just the truth of what the research shows. They go to see those individuals with back pain. Okay, you have low back pain, let's get you some NSAIDs. Probably Ideally not opioids, but we still see that happening bizarrely enough. And the medication body becomes sensitized to the medication over the course of a week, two weeks, maybe a month. They haven't addressed the actual cause of the issue. The patient goes back to all of the lifestyle that caused it in the first place, whether that's sitting, whether that's lack of exercise, whatever it might be. The medication doesn't help, patient goes back in. Hey, the doc, this still hurts. Well, let's get an MRI. And the MRI, if they're over about 30 to 35 years old, of course, comes back with findings. And we see that here. And then it becomes, well, we do see you have a disc bulge. Well, we do see you have some light stenosis. You know what, I think the best thing would be an injection. And then we see the proliferation of ESIs, epidural steroid injections. Well, guess what? That's still medication. Body becomes sensitized structural challenge hasn't been addressed, patient goes back in, they have three of those in a year and off to the surgeon for a surgical consult, at which point they it's pretty much guaranteed, of course, that they're gonna see something in the mri. Patient had potentially radiculopathy, so of course they have a disc pressing on a nerve. Medication is very unlikely to solve that problem. Yes, it can decrease inflammation, but this is what happens day in and day out. And this is why I stress so much on this show each and every week to take the information we know, to apply it in your practice and to apply it in the conversations that you have. That was the foundation of the evidence based chiropractor and still is today about bridging the gap and building relationships with other healthcare providers. Who has your ideal patients in their practice? I don't care what their credentials are. The bottom line is you want to get with those individuals, help them understand what you do and make it easy for them to refer into your practice. Why? Well, will it help build your practice? Of course it will. But it will also help better the health of the people in your community because there is just too much misinformation out there, too many people that have no idea what chiropractic is, how it can help them, and they're going through the other side of the coin of healthcare. And many times it's not pretty. Now, of course there are those cases that work out, which is great. But we all know movement is key to health, movement is key to healing. And if you're not getting in there and moving as a core component of your rehab, of your relief, of your program, of your care, whatever it might be, that is a huge problem. So let's identify some of the key points the researchers pointed out in this article. They say, quote, the relevance of lumbar degenerative MRI findings for the development of low back pain is unclear due to a few cohort studies with limited sample size where general population samples are imaged and their low back pain status is tracked over time. They also found, quote, this population study found only small associations between MRI findings such as disc degeneration or herniation and present or future low back pain. And they found, quote, future research aiming to identify subgroups of patients with low back pain could evaluate more advanced imaging protocols in combination with non imaging clinical findings. So bottom line is this they found small associations between disc degeneration, herniation in past or future low back pain. This is also a key talking point with your patients. If they get that MRI report back and they see there's a disc bulge, a disc herniation, a disc, whatever it might be, extrusion, fragment. Now, typically fragment or extrusion is going to probably cause pain, but if they see a degenerate, degenerative changes, excuse me, if they see a herniation, if they see a bulge that gets implanted in people's mind and they feel like they have to, that it's only a matter of time, that there's a lot of fear associated with that. And one of the most important things we can do, being their healthcare providers, is letting them know that their body's resilient, letting them know that it's about a balance of strength and flexibility. Letting them know that. Hayes, 80% of people, whether you have pain or don't, are gonna have findings on an mri, at least one finding. So don't stress about it. Is it nice to know that they have something going on? Of course. Because now you're able to focus your care, you're able to focus the modalities that you use. You can be more specific with what you're up to, but it's not a sentence that imposes chains on them for the rest of their lives or they have to feel weak or they feel like it's just, it's gonna go at any moment in time. It's just not true. Based upon the literature, however, because of how our system is set up and because of decades of how it's worked, there's a lot of fear associated with that. And you can't blame the individual. And the other thing is, you need to be cautious about how you speak. Because I feel like in many times, us as healthcare professionals, as chiropractors, we can't associate with not knowing. In other words, we have so much training on the spine, on a neuromusculoskeletal care, that it's difficult to take a step back and say, how would somebody approach this if they knew nothing? And many people that come into your practice, they have no idea how their body works. When they see a MRI report, when they've been told something by their pain management doctor, if they go for a surgical consult. This is life changing in terms of just being embedded in their mind as far as what's going on with them and what the best thing to do is. Now, I think for us as chiropractors, what we can do is continue to bridge the gap, continue to have fantastic conversations with our patients, continue to use imaging as one of the tools to guide our clinical course of care, but really listen to the patient, understand what they're going through, talk with them and emphasize and empower them to understand that their body is resilient, that it is all about a balance of strength and flexibility, and that healing typically occurs through movement, not through medication. So if you want to take some of those clinical pearls, please take with it and run with it. If you want to give feedback on this episode, I'd love to hear that. You can hit me up jeff the evidencebasedchiropractor.com and if you have not left a rating or review for this podcast, I would super, super appreciate it. It helps more and more docs find out about what we're up to. So scroll on down if you're listening on your phone, tap how many stars leave a few sentences. I would greatly, greatly appreciate it. I love seeing that feedback. Thank you so much for tuning in. Before we wrap up today, I want to say a few words about Power Step. Power Step creates incredibly fantastic orthotics. These were designed by a podiatrist over 30 years ago. My father uses Powerstep. He loves it. He has had foot and back issues for a long time and these were a they continue to be a game changer for him. If you want to try a free pair for yourself, powerstep is offering this to listeners of the Evidence based chiropractor podcast. Pro.powerstep.com sample pro.powerstep.com sample try it out for yourself, see what's up. I love this product. I'm going to drop a link down in the show notes as well. Grab a free sample pro powerstep Docs, thank you so much for tuning in. Have a fantastic week in practice and I will talk to you soon.

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